OBSTRUCTIVE SLEEP APNEA and WORK Treatment Update David Claman, MD Professor of Medicine Director, UCSF Sleep Disorders Center 415-885-7886 Disclosures: None Chronic Sleep Deprivation (0 v 4 v 6 v 8 hrs) Lapses in Concentration: big increase if 6 hours (Van Dongen Sleep 2003) 1
DEFINITIONS: Apnea: complete cessation of airflow lasting 10 second or more Hypopnea: reduced airflow for 10 seconds or more, associated with 4% oxygen desaturation 3% is AASM recommendation; 4% is Medicare definition Apnea-hypopnea Index (AHI): average number of apneas & hypopneas per hour of sleep AHI < 5 is normal AHI 5-14 - Mild OSA AHI 15-29 - Moderate OSA AHI >= 30 - Severe OSA Wisconsin Sleep Cohort: prevalence of 2% women and 4% in men based on AHI > 5 and symptoms of daytime sleepiness; NEJM 1993; 328(17):1230-5. CLINICAL PREDICTORS OF OSA Screening questionnaires Epworth Sleepiness Scale: range 0-24 for 8 questions Normal score < 10 In OSA population, score correlates with AHI SLEEP 1991; 14(6):540-5 Berlin 10 questions validated in primary care Snoring, apnea, fatigue, sleepiness at wheel, Hypertension Ann Intern Med. 1999 Oct 5;131(7):485-91 STOP-BANG used in Anesthesia Snoring, Tired, Observed apnea, Pressure (HTN), BMI 35, Age 50, Neck circumference 40 cm (15.75 inches), Gender (male) Arch Otolaryngol Head Neck Surg. 2010 Oct: 136(10):1020-4 2
EPWORTH SLEEPINESS SCALE https://www.slhn.org/docs/pdf/neuro-epworthsleepscale.pdf Score < 10 is normal; 10-15 is situational sleepiness; 15 > excessive CLINICAL PREDICTORS OF OSA http://www.stopbang.ca/osa/screening.php STOPBANG 8 Questions High risk: yes to 5-8 questions; Medium risk yes on 3-4;Low risk yes on 0-2 Snoring Tired (fatigue) Observed Apnea Pressure (Hypertension) BMI >35 ( 30 is considered obese) Age >50 Neck size > 17 inches for men or >16 inches for women Gender male COMPARISON OF QUESTIONNAIRES GE Silva et al. J Clin Sleep Med. 2011; 7(5): 467 472 3
PREVALENCE OF SLEEP APNEA 602 working subjects, age 30-60, studied by overnight polysomnography Obstructive sleep apnea defined as both AHI > 5 and hypersomnolence 9% of women had AHI >5; 22% c/o hypersomnolence; yields 2% prevalence 24% of men had AHI >5; 15% c/o hypersomnolence; yields 4% prevalence T Young; NEJM 1993;328:1230-5 Cumulative Percentage of New Fatal (A) & non-fatal (B) Cardiovascular Events JM Marin et al. Lancet. 2005 Mar 16;365(9464):1046-53 KEY POINTS: 1. Increased mortality seen if AHI>30 2. CPAP reduced this risk CPAP as Secondary Prevention of Cardiovascular Events in OSA Randomized trial CPAP v usual care; n=2717 Age 61; 80% men; AHI 29; BMI 28 Pre-existing CAD or cerebrovascular disease Mean f/u 3.7 years; CPAP use 3.3 hrs No change in primary cardiovascular outcomes CPAP did improve quality of life measures McEvoy RD et al. NEJM 2016;375:919-931 4
CPAP to Prevent Cardiovascular Events McEvoy RD et al. NEJM 2016;375:919-931 OSA TREATMENT Weight loss (10% weight loss reduces AHI 25%) Avoid alcohol for 3+ hour before bed Postural training (side sleeping since apnea worse on back) Nasal patency (treat allergies) CPAP (including autocpap; Bi-level less common) Oral (dental) appliances ENT surgery: Tonsillectomy in kids UPPP in adults <50% success Hypoglossal nerve stimulator now FDA approved Nasal expiratory resistor (Provent) Nasal adhesive micro-valve resistor delivers approx 5 cm pressure WHY TREAT SLEEP APNEA? Improve patient s daytime alertness (big motivator!) Reduce cardiovascular risk Still debated Improve partner s sleep 5
MANDIBULAR ADVANCEMENT DEVICES Advancement of mandible Enlarge airway behind tongue, but may also enlarge airway behind palate ORAL APPLIANCE THERAPY: ANTERIOR MANDIBULAR REPOSITIONING Ferguson;Chest 1996;109:1269-75 WHEN TO USE ORAL APPLIANCES? Mild to moderate OSA (AHI <30) Intolerant of CPAP After failed UPPP Significant overbite Must have teeth! Relative contraindications: Severe OSA with severe oxygen desaturation TMJ symptoms 6
CPAP Site Non-specific CPAP: Nasal Mask or Pillows LONGTERM USE OF CPAP Best compliance if AHI >30 & ESS >10 McArdle N et al. AJRCCM 1999;159:1108-1114 7
SURGICAL THERAPY (primarily if non-compliant with CPAP) Nasal Surgery Tonsillectomy: if 3-4++, can be 80-90% success (common approach in kids) Uvulopalatopharyngoplasty (UPPP) reduces AHI by 50% in 40-50% of patients For snoring: laser or radiofrequency Mandibular advancement Genioglossus advancement with hyoid Mandibular-maxillary osteotomy & advancement Hypoglossal Nerve Stimulator Tracheotomy remains gold standard Question 1 Based on sleep deprivation data, when do shorter sleep hours cause more symptoms? A. 8 hours B. 7 hours C. 6 hours D. 4 hours Question 2 Which of the following is NOT part of STOPBANG? A. BMI B. Alcohol C. Hypertension D. Observed apnea 8